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Fill out this form to request a free case review by a personal injury lawyer.
were you or a loved one injured?
type of personal injury case:
employer's name:
injured person's job title:
injured person's job description:
what toxic substance, chemical or toxin was the injured person exposed to:
describe the toxic exposure:
name of doctor or healthcare provider who committed medical malpractice:
name of hospital or medical facility where medical malpractice occurred:
describe the medical malpractice or negligence:
name of person, entity or company who caused the accident or injury:
date of medical malpractice or negligence:
name of defective product:
name of product manufacturer:
describe the product defect and/or your product defect complaint:
was the product recalled:
name of drug taken or prescribed:
name of drug manufacturer:
when did you start taking the drug:
when did you stop taking the drug:
what dosage of the drug was taken:
name of defective medical device or product:
name of medical device manufacturer:
describe the medical device defect and/or your medical device complaint:
was the medical device or product recalled?
describe your personal injury claim:
date of injury or accident:
state where injury or accident occurred:
name of company/person/entity that owns property where injury occurred:
type of injury or injuries suffered:
- birth injury
- brain damage
- broken bone(s) or fracture(s)
- bleeding
- blindness or vision injury
- burn injury
- cancer
- coma
- concussion
- contusion or bruising
- chronic pain
- damaged or ruptured organs
- disfigurement
- dislocation
- hearing loss
- heart attack, stroke or embolism
- intellectual impairment
- infection
- lacerations, cuts & punctures
- loss of motor function
- nerve damage
- paralysis, quadriplegia or paraplegia
- respiratory injury
- scars
- scrapes, scratches & bruises
- severed limb(s) or loss of body part(s)
- spinal cord injury
- sprains, strains or tears
- wrongful death
- other personal injury
describe injury or injuries suffered:
type of property where injury occurred:
- residential property (e.g., house)
- commercial property (e.g., business)
- government property
- other type of property
describe the injuries, side effects, illnesses, diseases or symptoms suffered after taking the drug:
how severe is the injury?
is the injury permanent?
what part of body, if any, was injured:
- head injury
- brain injury
- neck injury
- shoulder injury
- back injury
- thorax or chest injury
- abdomen injury
- pelvis injury
- arm or elbow injury
- hand, wrist, finger or thumb injury
- hip injury
- leg injury or thigh injury
- knee injury
- eye, nose, mouth, ear or face injury
- foot, ankle or toe injury
- skin injury
- internal organ injury
- other bodily injury
other parts of body injured:
medical treatment received:
- hospital or emergency room ER
- ambulence or medical transport
- treated by physician or doctor
- prescribed drugs or medication
- surgery or surgical procedure
- stiches, staples or bandages
- crutches and/or wheelchair
- casts and/or braces
- prosthetic
- amputation
- physical therapy PT
- occupational therapy OT
- chiropractic treatment
- rehabilitation or rehab
- x-ray, CT or CAT scan or MRI
- other medical treatment
describe medical treatment received:
damages & losses suffered:
- medical bills & expenses
- lost wages, income or earnings
- missed work
- pain and suffering
- loss of consortium
- loss of enjoyment of life
- loss of a loved one
- property damage
- other personal injury damages
describe any damage or loss suffered:
estimated medical bills & expenses:
estimated lost wages or loss of income:
gender of injured person:
age of injured person:
your first name:*
your last name:*
name of injured person, if different, and relationship to you:
address:*
city:*
state:*
zip / postal code:*
daytime phone number*
evening phone number*
email:*
terms & conditions*
- I agree to the terms & conditions
Email
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